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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800077
Report Date: 04/28/2026
Date Signed: 04/28/2026 02:15:39 PM

Document Has Been Signed on 04/28/2026 02:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:AGAPE COTTAGEFACILITY NUMBER:
331800077
ADMINISTRATOR/
DIRECTOR:		ALEJANDRA CONTRERASFACILITY TYPE:
740
ADDRESS:3503 BRYCE WAYTELEPHONE:
(951) 276-8006
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 6CENSUS: 4DATE:
04/28/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Per Administrator Rose SumadsadTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 4/28/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced 1-year required visit to the facility. LPA Flores met with staff Corazon Sevilleno and explained the purpose of the visit. LPA Flores was granted entry into the facility and a tour was conducted alongside staff Corazon. During the inspection, LPA Flores observed the following:
The facility is a single-story structure which consisted of (6) six resident bedrooms, garage, kitchen, living room, dining room, and laundry room. The office documented on the facility sketch has now been converted to a staff bedroom. Resident bedrooms were observed to be equipped with the required bedding, furniture, and functional lighting. Bathrooms were required with grab bars and slip resistant material in the designated areas. LPA observed a fully charge fire extinguisher mounted on the wall near the kitchen. The kitchen was observed to be organized and sanitary. LPA observed a drawer equipped with a lock designated for knives and other sharp items. LPA observed a cabinet equipped with a locked designated for disinfectants and other cleaning solutions. Medication was observed to be centrally stored and made inaccessible to residents and unauthorized representatives. LPA observed books and other activities stored in the TV room. Carbon monoxide and smoke detectors were observed to be fully operable. Water temperature was measured within the required limits. Laundry services are provided on-site. LPA observed a locked cabinet which stored detergents. The facility maintained adequate supply of towels and linen for resident-use. Per Administrator Rose Sumadsad, there are no firearms and/or ammunition on the premises. A records review was conducted for (4) four out of (4) four residents. (3) Three of (4) four resident files were missing Appraisals/Needs and Service Plans and Functional Capabilities assessments. (3) Three staff record were reviewed. Records included but not limited to personnel records, health screening with TB results, background and fingerprint clearance, valid first-aid/CPR certification, and relevant training's. Health and safety concerns were address with Administrator and will be cited on the attached LIC809D.
An exit interview was conducted and a copy of the LIC809/D along with appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Valerie Flores
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/28/2026 02:15 PM - It Cannot Be Edited


Created By: Valerie Flores On 04/28/2026 at 11:58 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AGAPE COTTAGE
FACILITY NUMBER: 331800077

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)(E)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (E) Section 87463, Reappraisals; and

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in (3) three out of (4) four residents did not have an appraisal on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2026
Plan of Correction
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Administrator agreed to provide LPA with an email copy of Resident #1 (R1), Resident #2 (R2), and Resident #3's (R3) reappraisal conducted along with a written and signed statement for all managing members confirming that they have read and acknowledged section 87506 in its entirety. Proof shall be submitted to LPA via email by close of business on 5/19/2026.
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above as the facility maintained (6) six 1.25 Liter water bottles as the emergency water supply for a current census of (4) four residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2026
Plan of Correction
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Administrator agreed to purchase additional emergency water and provide photo proof of purchase via email by Close of Business on 5/1/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Valerie Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2026


LIC809 (FAS) - (06/04)
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